Professional Documents
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Tgl/Jam : No. RM :
Ruangan : Diagnosa Medis :
IDENTITAS
Nama / Inisial : Jenis Kelamin :
Umur : Status Perkawinan :
Agama : Sumber Informasi :
Pendidikan : Hubungan :
Pekerjaan :
Suku/Bangsa :
Alamat :
RIWAYAT SAKIT DAN KESEHATAN
Keluhan utama saat MRS :
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Keluhan utama saat pengkajian :
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Riwayat Penyakit saat ini :
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Riwayat Alergi :
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Riwayat Pengobatan :
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BREATHING
Jalan Nafas : Paten Tidak Paten
Obstruksi : Lidah Cairan Benda Asing Tidak Ada
Muntahan Darah Oedema Tidak Ada
Suara Nafas : Snoring Gurgling Stidor Tidak Ada
Nafas : Spontan Tidak Spontan
Geraka dinding dada : Simetris Asimetris
Irama Nafas : Cepat Dangkal Normal
Pola Nafas : Teratu Tidak teratur
Jenis : Dispnoe Kusmaul Cyene Stoke Lain..........
Suara Nafas : Vesikuler Stidor Whezzing Ronchi
Sesak Nafas : Ada Tidak Ada
Cuping hidung: Ada Tidak Ada
Retraksi otot bantu nafas : Ada Tidak Ada
Pernafasan : Pernafasan dada Pernafasan Perut
Batuk : Ya Tidak Ada
Sputum : Ya, Warna: ................. Konsistensi:............... Volume:......... Bau:........
Tidak
RR : .............x/menit
Alat bantu nafas : OTT ETT Trakeostomi
Ventilator, Keterangan : ..................
Oksigenasi : ..........lt/menit Nasal Kanul Simpel mask Non RBT mask
RBT mask Tidak Ada
Lain : ................................
Masalah Keperawatan :
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BLOOD
Nadi : Teraba Tidak Teraba N : ................x/menit
Tekanan Darah : ........................mmHg
Pucat : Ya Tidak
Sianosis : Ya Tidak
CRT : <2 detik >2 detik
Akral : Hangat Dingin
Pendarahan : Ya, Lokasi ...................... Jumlah ..............cc Tidak
Turgor : Elastis Lambat
Diaphoresis : Ya Tidak
Riwayat kehilangan cairan berlebih : Diare Muntah Luka Bakar
IVDF : Ya Tidak, Jenis cairan ..................................
Lain : ..................
Masalah Keperawatan :
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BRAIN
Kesadaran : Compos mentis Delirum Somnolen Apatis Koma
GCS : Eye ........ Verbal ....... Motorik ........
Pupil : Isokor Unisokor Pinpoint Medriasis
Refleks Cahaya : Ada Tidak Ada
Reflek Fisiologis : Patela (+/-) Lain – lain ..............
Refleks Patologis : Babinzky (+/-) Kerning (+/-) Lain – lain ...................
Refleks Bayi : Refleksi Rooting (+/-) Refleksi Moro (+/-)
(Khusus PICU/NICU) : Refleksi sucking (+/-)
Bicara : Lancar Cepat Lambat
Tidur Malam : ....................... jam Tidur siang : ......................jam
Ansietas : Ada Tidak Ada
Lain : .............
Masalah Keperawatan :
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BLADDER
Nyeri pinggang : Ada Tidak Ada
BAK : Lancar Inkontinensia Anuri
Nyeri BAK : Ada Tidak Ada
Frekuensi BAK : ........................... Warna : ........................ Darah : Ada Tidak Ada
Kateter : Ada Tidak ada, Urine output : ....................
Lain : ........................
Masalah Keperawatan :
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BOWEL
TB : .............cm BB : .............Kg
Nafsu makan : Baik Menurun
Keluhan : Mual Muntah Sulit menelan
Makan : Frekuensi ...............x/hari Jumlah .................Porsi
Minum : Frekuensi ...............gls/hari Jumlah ...............cc/hari
Perut Kembung : Ya Tidak
BAB : Teratur Tidak
Frekuensi BAB : ....... x/hari Konsistensi : ............. Warna : .......... darah (+/-) / lender (+/-)
Lain : ..............
Masalah Keperawatan :
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BONE
Nyeri : Ada Tidak
Problem : ............................................ Qualitas/ Quantitas : ................................
Regio : ............................................ Skala : ................................
Timing : ............................................
Kekuatan Otot : ............................................
Deformitas : Ya Tidak Lokal ........................
Contusio : Ya Tidak Lokal ........................
Abrasi : Ya Tidak Lokal ........................
Penetrasi : Ya Tidak Lokal ........................
Edema : Ya Tidak Lokal ........................
Luka Bakar : Ya Tidak Lokal ........................
Grade : ......................%
Masalah Keperawatan :
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ANALISA DATA DAN DIAGNOSA KEPERAWATAN INTENSIF
No Diagnosa Keperawatan
RENCANA TINDAKAN KEPERAWATAN
Nama : No.RM :
Umur / JK : Diagnosa Medis :
Ruangan :
Nama : No.RM :
Umur / JK : Diagnosa Medis :
Ruangan :
No.
No Tgl / Jam Evaluasi Paraf
Dx
No Tgl / Jam No. Evaluasi Paraf
Dx